No coverage / Coverage terminated

Many times we come across the denial "Denied for No coverage or Coverage terminated", whenever we come across this denial we usually assume that the patient does not have coverage. This is not always true, let us review the following scenarios.

Scenario 1
The payor issued a new ID to the patient, while the claim was submitted with the old ID, hence the denial. So we need to call the payor or go online and search the patient. This way we can pull the patient's correct ID, update that in our records and have the claim resubmitted.

Scenario 2
The denial could be in error in which case we can verify this by calling the payor or checking online. We will also know by checking the claim history, if the payor has been paying claims before and after the date of service being denied by them, then it is obvious that this claim has been denied in error. A call to the payor will resolve this claim.

Scenario 3
The denial could be correct we can verify this by calling the payor. We need to call or check online and see whether we are able to pull up this patient, if we cannot find any information about the patient then we need to contact the patient. We can send a patient statement stating that the charges are being billed to the patient as the insurance has denied citing no coverage. If the patient has a new insurance, he would update us on receiving the statement. With the new insurance information the claim can be resubmitted.

PPOs

Most Americans who have health insurance through their employer (or who are self-insured) are enrolled in some type of a managed care plan - either an HMO or PPO. The most common types of managed care plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Less common are point-of-service (POS) plans that combine the features of an HMO and a PPO.

All managed care plans contract with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs, x-ray centers, and medical equipment vendors. This group of contracted health care providers is known as the health plan's "network."

In some types of managed care plans, you may be required to receive all your health care services from a network provider. In other managed care plans, you may be able to receive care from providers who are not part of the network, but you will pay a larger share of the cost to receive those services. 

Preferred Provider Organizations (PPOs)

A preferred provider organization (PPO) is a health plan that has contracts with a network of "preferred" providers from which you can choose. You do not need to select a PCP and you do not need referrals to see other providers in the network.
If you receive your care from a doctor in the preferred network you will only be responsible for your annual deductable (a feature of some PPOs) and a copayment for your visit. If you get health services from a doctor or hospital that is not in the preferred network (known as going "out-of-network") you will pay a higher amount. And, you will need to pay the doctor directly and file a claim with the PPO to get reimbursed.

Features of PPOs

• You can choose doctors, hospitals, and other providers from the PPO network or from out-of-network. If you choose an out-of-network provider, you most likely will pay more.
• You can receive care from any doctor you choose. But remember, you will pay more if the doctors you choose are not "preferred" providers.
• You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. And, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.
• If you get your healthcare from a network provider you usually do not need to file a claim. However, if you go out of network for services you may have to pay the provider in full and then file a claim with the PPO to get reimbursed. The money you receive from the PPO will most likely be only part of the bill. You are responsible for any part of the doctor's fee that the PPO does not pay.
• In most PPO networks you will only be responsible for the copayment. Some PPOs do have an annual deductable for any services, in network or out of network.
• If you choose to go outside the PPO network for your care, you will need to pay the provider and then get reimbursed by the PPO. Most likely, you will have to pay an annual deductable and coinsurance. For example, if the out-of-network doctor charged you $100 for a visit, you are responsible for the full amount if you have not met your deductable. If you have met the deductable, the PPO may pay 60%, or $60 and you will pay 40%, or $40.

HMOs

 Most Americans who have health insurance through their employer (or who are self-insured) are enrolled in some type of a managed care plan - either an HMO or PPO. The most common types of managed care plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Less common are point-of-service (POS) plans that combine the features of an HMO and a PPO.

All managed care plans contract with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs,  and medical equipment vendors. This group of contracted health care providers is known as the health plan's "network."

In some types of managed care plans, you may be required to receive all your health care services from a network provider. In other managed care plans, you may be able to receive care from providers who are not part of the network, but you will pay a larger share of the cost to receive those services.

Health Maintenance Organizations (HMOs)

If you are enrolled in a health maintenance organization (HMO) you will need to receive most or all of your health care from a network provider. HMOs require that you select a primary care physician (PCP) who is responsible for managing and coordinating all of your health care.
Your PCP will serve as your personal doctor to provide all of your basic healthcare services. PCPs include internal medicine physicians, family physicians, and in some HMOs, gynecologists who provide basic healthcare for women. For children, you can select a pediatrician or a family physician to be their PCP.
If you need care from a specialist in the network or a diagnostic service such as a lab test or x-ray, your primary care physician (PCP) will have to provide you with a referral. If you do not have a referral or you choose to go to a doctor outside of your HMO's network, you will most likely have to pay all or most of the cost for that care.

Features of HMOs

• You must choose doctors, hospitals, and other providers in the HMO network.
• The HMO will not provide coverage if you do not have a PCP.
• You will need a referral from your PCP to see a specialist (such as a cardiologist or surgeon) except in emergency situations. Your PCP also must refer you to a specialist who is in the HMO network.
• All of the providers in the HMO network are required to file a claim to get paid. You do not have to file a claim, and your provider may not charge you directly or send you a bill.
• The only charges you should incur for in-network services are copayments for doctor's visits and other services such as procedures and prescriptions.
• Except for certain types of care that may not be available from a network provider, you are not covered for any out-of-network services.

Billing Process

Tasks in Medical Billing

1. Insurance Verification
2. Patient Demographic Entry
3. CPT & ICD Coding
4. Charge Entry
5. Claim Submission
6. Payment Posting
7. A/R Follow-up
8. Denial management
9. Reporting
   

Insurance verification
Patient provides the insurance details to the Physician's front office. The Physician's front office verifies the patient's insurance details by calling the insurance company or through online verification.

Patient Demographic Entry
The Patient Demographic entry is the process of  capturing all the information of a patient such as his Name, Date of Birth, Sex, SSN, Address, Contact details e.t.c. in the practice management software.

CPT & ICD Coding
The Physician creates the progress note for the Patient encounter. From the progess notes the Coder picks the billable Dx / ICD codes  and the Procedure / CPT codes, in some practices the Physician themselves code the ICD and the CPT codes.

Charge Entry
The Charges are entered into the Practice management software and a Claim is generated.

Claim Submission
Once the Claim is generated the claims have to be sent electronically or thru paper depending upon the insurance company. The claims are checked for errors and then submitted to the clearinghouse for onward submission to the insurance companies.

Payment Posting
The payments received from the insurance companies are posted in the practice management software. The Explanation of Benefits received from the insurance companies are reconciled and the denials are also captured.

A/R Follow-up
The insurance companies are called with respect to each outstanding claim and the reason for the denial of the claims is ascertained.

Denial Management
Depending upon the status of each claim and the type of denial, different denial actions need to be taken to ensure that the claim is paid. Prompt and proper denial management will ensure that the Accounts receivable is under control.

Reporting
AR Reports, Aging reports and Collections reports indicate as to how the Accounts receivable is being managed and how the AR is faring across different collection buckets. The practice generates different reports to keep track of collections, performance and for analysis.